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General NPI Number Information
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NPI Number | 1821684929
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Entity Type | Organization
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Legal Business Name | SHELLY K. CLARK, DENTISTRY FOR CHILDREN
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Dates
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Enumeration Date | 12/14/2020
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Last Update Date | 12/14/2020
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Provider Practice Location Address
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Address Line | 4450 E HIGHWAY 287
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City | MIDLOTHIAN
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State | TX
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Zip | 76065-5576
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Country | US
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Telephone | 972-723-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 4450 E HIGHWAY 287
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City | MIDLOTHIAN
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State | TX
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Zip | 76065-5576
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Country | US
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Telephone | 972-723-0111
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHELLY CLARK
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Credential | DDS
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Telephone | 972-291-4281
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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